CIVIL UNION (if applicable)MARITAL STATUS * / CIVIL UNION (if applicable)
HOW LONG HAVE YOU KNOWN THE APPLICANT
FORM NAME ITEM #
BOAT # VEH #
FORMS AND ENDORSEMENTS (Attach ACORD 829, Forms and Endorsements Schedule, if more space is required)
LOC # FORM NUMBER EDITION DATE COPYRIGHT OWNER CODE
SUSTAINED ACTUAL LOSS OF USE
** *
Not Applicable in North Carolina
Named Storm Percentage Deductible in North Carolina
HO FORM #: $ $ $ $ $ % MAX HURRICANE** HURRICANE* $ $ $ $ AMOUNT TYPE % % % % PERCENT $ $ $ $ DEDUCTIBLE AMOUNT LIMIT INCLUDED INCLUDED INCLUDED OPTION
REPL COST - CONTENTS REPL COST - DWELLING REPL COST - FULL VALUE
COVERAGE
* Includes Dwelling, Other Structures, Personal Property, Loss of Use
TYPE % % % ANNUAL NAMED THEFT WIND / HAIL BASE PREMIUM % DEDUCTIBLE PERCENT
MEDICAL PAYMENTS EA PER PERSONAL LIABILITY EA OCC LOSS PERSONAL PROPERTY COVERAGE LIMIT BLANKET * DWELLING OTHER STRUCTURES PREMIUM $ $ $ $ $ $ $ $ $ $ $ $ $ $ COVERAGES / LIMITS OF LIABILITY LOC #:
DATE AGENT LAST INSPECTED PROPERTY EFFECTIVE DATE
STATUS OF TRANSACTION RENEW
NEW
POLICY CHANGE
POLICY CHANGE TIME AM
PM
Check if same as Applicant
* This field may not be utilized for policyholders applying for residential property insurance in CA. DATE OF BIRTH SOCIAL SECURITY # MARITAL STATUS * /
DATE OF BIRTH SOCIAL SECURITY #
* This field may not be utilized for policyholders applying for residential property insurance in CA.
YEARS WITH PREVIOUS EMPLOYER: YEARS IN CURRENT OCCUPATION:
YEARS WITH PREVIOUS EMPLOYER: YEARS IN CURRENT OCCUPATION:
YRS WITH CURRENT EMPLOYER:
YRS WITH CURRENT EMPLOYER:
RENTED OWNED
Check if same as mailing address CURRENT RESIDENCE
NAMED INSURED(S)
POLICY NUMBER
EFFECTIVE DATE EXPIRATION DATE
CARRIER NAIC CODE
PLAN FACILITY CODE
DATE AT CURRENT RESIDENCE:
PHONE # HOME BUS CELL PRIMARY
PHONE #
SECONDARY HOME BUS CELL
CO-APPLICANT'S ADDRESS CO-APPLICANT'S NAME (First, Middle, Last)
PRIMARY E-MAIL ADDRESS: SECONDARY E-MAIL ADDRESS:
CO-APPLICANT'S OCCUPATION (State Nature of Business if Self-Employed) CO-APPLICANT'S EMPLOYER NAME AND ADDRESS
PHONE # HOME BUS CELL PRIMARY
PHONE #
SECONDARY HOME BUS CELL
APPLICANT'S EMPLOYER NAME AND ADDRESS APPLICANT'S OCCUPATION (State Nature of Business if Self-Employed) YEARS AT PREVIOUS ADDRESS (if less than three years):
PREVIOUS ADDRESS
SECONDARY E-MAIL ADDRESS: PRIMARY E-MAIL ADDRESS: APPLICANT'S NAME (First, Middle, Last) APPLICANT'S MAILING ADDRESS
APPLICANT INFORMATION FAX (A/C, No): AGENCY NAME: CONTACT
(A/C, No, Ext): PHONE
SUBCODE: CODE:
AGENCY CUSTOMER ID: ADDRESS:
YEARS, AT THIS OR ANY LOCATION? ANY LOSSES, WHETHER OR NOT PAID BY INSURANCE, DURING THE LAST
APPLICANT'S INITIALS: IF YES, INDICATE BELOW
Y / N LOSS HISTORY (Y / N) DISPUTE IN (C)OMPANY (A)GENT LOSS TYPE $ $ $ ENTERED BY DESCRIPTION OF LOSS
LOSS DATE CAT # AMOUNT PAID
NO PRIOR COVERAGE
PRIOR POLICY NUMBER PRIOR CARRIER
PRIOR COVERAGE
EXPIRATION DATE
LOCATION SCHEDULE
LOC # STREET CITY COUNTY STATE ZIP + 4
SEMI-RESISTIVE WIND CLASS RESISTIVE STORM SHUTTERS B A
HURRICANE RESISTIVE GLASS WINDSTORM
INDOORS ABOVE GROUND NO MASONRY FLOOR NONE FUEL STORAGE TANK LOCATION
OUTDOORS ABOVE GROUND
INDOORS ABOVE GROUND MASONRY FLOOR
OUTDOORS BELOW GROUND
FUEL LINE LOCATION
UNDER GROUND THROUGH FOUNDATION DIVING BOARD SLIDE IN GROUND ABOVE GROUND APPROVED FENCE SWIMMING POOL NONE
RENOVATIONS WIRING PLUMBING HEATING ROOFING EXTERIOR PAINT
PART COMP YEAR CLASS SPECIFIC RATING CLOSED NONE FOUNDATION OPEN IN FIRE DISTRICT IN CITY LIMITS IN PROT SUBURB DWELLING LOCATION RATING CREDITS NON-SMOKER LIGHTNING PROTECTION MANNED SECURITY
OFF PREMISE THEFT EXCL RESIDENTS
# ROOMS
# APARTMENTS
# FAMILIES
# HOUSEHOLD
# WEEKS RENTED TAX CODE
BLDG CODE GRADE
INSPECTED (Y/N):
FIREPLACES (Enter # or 0 for none)
PRE-FAB CHIMNEYS HEARTHS
WOOD STOVE INSERT SQ FT BREEZEWAY AREA SQ FT GARAGE AREA SQ FT BASEMENT AREA SQ FT TOTAL LIVING AREA $ REPLACEMENT COST $ MARKET VALUE YEAR BUILT NEIGHBORS ROAD ROOF MATERIAL ROOF CONDITION AVERAGE EXCELLENT
GOOD BELOW AVG
ANY KNOWN LEAKS? (Y/N)
BELOW AVG GOOD EXCELLENT AVERAGE PLUMBING CONDITION TOWNHOUSE ROWHOUSE APARTMENT DWELLING CONDOMINIUM CO-OP RESIDENCE TYPE CONSTRUCTION TYPE MASONRY VENEER MASONRY FRAME % OCCUPIED DAILY VISIBLE TO VISIBLE FROM SECURITY EIFSS (on studs)
SHINGLE STUCCO ALUMINUM SIDING
VINYL SIDING / PLASTIC SIDING
CEDAR, WOOD,
EIFSCB (on cinder block)
YEAR EIFS INSTALLED:
%
FIRE DIST CODE FIRE DISTRICT NAME
DISTANCE TO TIDAL WATER Miles Feet COURSE OF CONSTRUCTION
RENOVATION BUILDERS RISK
RECONSTRUCTION
KNOB & TUBE WIRING
LAST INSPECTED DATE COPPER ALUMINUM FUSES ELECTRICAL SYSTEMS CIRCUIT BREAKERS NUMBER OF AMPS SPRING DOOR LOCK DEADBOLT PARTIAL SPRINKLER FULL
DATE HEATING SYSTEM LAST SERVICED:
SECONDARY HEAT NONE
PRIMARY HEAT NONE
LOCAL DIRECT CENTRAL BURG TEMP SMOKE SYSTEM
PROTECTION DEVICE TYPE
Y / N FIRE EXTINGUISHER PROT CLASS
TERRITORY
# UNITS FIRE DIV # FIRE DIVISIONS FIRE STATION MI FT FIRE HYDRANT DISTANCE TO $ PURCHASE DATE PURCHASE PRICE VACANT TENANT OWNER UNOCCUPIED OCCUPANCY USAGE TYPE SEASONAL PRIMARY SECONDARY FARM HOUSEKEEPING CONDITION AVERAGE EXCELLENT
GOOD BELOW AVG
RATING / UNDERWRITING LOC #:
PAYMENT PLAN (Attach ACORD 610, Premium Payment Supplement, if additional information is required)
FINANCE COMPANY Y/N PREMIUM FINANCED ? MORTGAGEE INSURED PAYOR
PRE-AUTHORIZED DRAFT/CHECK (PAC) PAYROLL DEDUCTION EFT CREDIT CARD CHECK CASH PAYMENT METHOD MONTHLY BI-MONTHLY QUARTERLY SEMI-ANNUAL ANNUAL FULL PAY
PAYMENT PLAN MAIL POLICY TO:
AGENT INSURED AGENCY BILL
DIRECT BILL - ACCT DIRECT BILL - POLICY
BILLING
BILLING ACCOUNT #: DEPOSIT AMOUNT: $ EST TOTAL PREMIUM: $
(Not applicable in NC) EQUIP BREAKDOWN BUSINESS PROP AWAY FROM HOME
$ DED $ LIMIT $ INC LIMIT $ LIMIT $ LIMIT $ LIMIT $ INCREASE INFLATION GUARD % $ $ $
LOSS ASSESSMENT LIMIT
$ LIMIT PROP DESC: CONST MATERIAL: MINE SUBSIDENCE $ WORKERS COMPENSATION - FULL TIME INSERVANT MED PAY (Y/N):
ANY OTHER RESIDENCE, NOT LISTED ON ANY APPLICATION, OWNED, OCCUPIED OR RENTED? 5.
4. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE PAST FIVE (5) YEARS?
3. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE PAST FIVE (5) YEARS? 1. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)
POLICY NUMBER POLICY NUMBER
LINE OF BUSINESS LINE OF BUSINESS
2. HAS ANY COVERAGE BEEN DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST THREE (3) YEARS? (Missouri Applicants - Do not answer this question)
GENERAL INFORMATION
Y / N EXPLAIN ALL "YES" RESPONSES
AGENCY CUSTOMER ID:
PREMIUM TYPE: DESCRIPTION Y / N: CODE TERR: $ $ $ $ TYPE: DESCRIPTION Y / N: CODE TERR: $ $ $ $ TYPE: DESCRIPTION Y / N: CODE TERR: $ $ $ $ TYPE: DEDUCTIBLE DESCRIPTION Y / N: OPTS LIMIT COVERAGE TYPE CODE TERR: APPL TO
(Applicable only in CA, MT, NV, NH, NJ, NY, ND, OH, OR, WA, WV and WY)
# OF EMPLOYEES:
(Not applicable in Arkansas) YES WINDSTORM EXCL LIMIT $ WATERCRAFT LIABILITY WATERCRAFT PHYSICAL DAMAGE LIMIT $ LIMIT $ INCLUDED $ WATER BACKUP OF SEWERS & DRAINS
INCR $ AGG $ UNSCHEDULED JEWELRY, WATCHES, FURS LIMIT $ INCLUDED UNIT-OWNERS ADDITIONS & ALTERATIONS SPECIAL COVERAGE INCLUDED SINK HOLE COLLAPSE LIMIT $ INCLUDED REFRIGERATED FOOD PRODUCTS $ LIMIT $ PREMIUM COVERAGE TYPE COVERAGE INFORMATION
$ $ $ $ $ $ $ $ $ $ $ $ INCR TOTAL INCR TOTAL INCR TOTAL INCR TOTAL INCR $ $ $ $ $ $ $ $ $ $ $ LIMIT $ $ $ $ $ $ $ $ $ MED PAY (Y/N):
$
PREMIUM
INCLUDED PLANTS, SHRUBS &
TREES STRUCTURE DESC: LIMIT OTHER STRUCTURES - INDIVIDUAL STRUC BUS/STRUCT DESC: STRUCT TYPE:
MED PAY (Y/N) : TERR: OT. STRUCTS $
INCR CONT NOT REQ REQ INCR CONTENTS OFFICE, PROFESSIONAL PRIVATE SCHOOL, STUDIO - RESIDENCE PREMISES LIMIT $ GOLF CARTS - PHYSICAL DAMAGE # PREMISES:
MEDICAL PAYMENTS (Y/N): INCIDENTAL
FARMING PERS LIAB
INCLUDED IDENTITY FRAUD EXP
DESCRIPTION: # GOLF CARTS: INCLUDED $ GOLF CARTS - LIABILITY LIABILITY $ $ EXCL PROP DAMAGE
EXCL LIABILITY PROPERTY
FUNGUS AND MOLD
CONTENTS $ BLDG FLOOD $ $ $ DEBRIS REMOVAL INCLUDED
$ FIRE DEPARTMENT
SERVICE CHARGE INCLUDED
$ # OF EMPLOYEES: LIMIT $ EMPLOYERS LIAB $ SILVERWARE $ $ $ $ $ $ GUNS MONEY SECURITIES ELECTRONIC APP IN AND OUT OF VEHICLE TOTAL TOTAL $ INCR $ $ INCR COV C
SPECIAL LIAB LIMIT
ELECTRONIC APP IN VEHICLE % % DED $ DED MAS VENEER: RETROFIT TYPE: TERR: EARTHQUAKE $ LIMIT LIMIT INCLUDED INCLUDED $ $ BUS PROP AT HOME
$ $ AGG INCLUDED % REBUILD $ INCR $ BUILDING ORD OR LAW COVERAGE $ INCLUDED COLLAPSE DUE TO HYDRO-STATIC PRESSURE INCLUDED THEFT BLDG MATERIALS BUILDERS RISK
OPTIONAL COVERAGES - ENDORSEMENTS LOC #: # PREMISES:
COVERAGE TYPE COVERAGE INFORMATION ADDITIONAL PREMISES LIABILITY EXTENSION ADDITIONAL RESIDENCE RENTED TO OTHERS LOC #: TERR: LOC #: TERR: LOC #: TERR: LOC #: TERR: # FAMILIES: # FAMILIES: MED PAY (Y/N):
$
$
% sq. ft. sq. ft. Y / N INCL EXCL Y / N
% $
COST OF PROJECT OCC DURING REN
MATERIALS UNATTACHED STRUC CHANGES
COMP DATE
START DATE INT EXT ADDITION ADD LEVEL
IS THE BUILDING ENTRANCE LOCKED? 3.
PHONE (A/C,No): MANAGER'S NAME:
IS THERE A SECURITY ATTENDANT? IS THERE A MANAGER ON THE PREMISES? 2.
1.
GENERAL INFORMATION - RENTERS AND CONDOS ONLY LOC #:
EXPLAIN ALL "NO" RESPONSES Y / N
OWNER'S NAME:
IS THE NAMED INSURED THE OWNER OF THE PROPERTY? (If "NO", provide the name of the owner) 16.
IS THERE AN APPROVED CARBON MONOXIDE ALARM IN OPERATING CONDITION WITHIN THE MANDATED NUMBER OF FEET OF EVERY ROOM USED FOR SLEEPING PURPOSES? (IL - 15 FT) (no explanation needed)
15.
NAME OF COMMUNITY: 13. IS THE RESIDENCE IN A GATED COMMUNITY?
CLEANUP/SUBLIMIT: LIMIT:
INSURANCE COMPANY:
12. IF A FUEL TANK IS ON PREMISES, HAS OTHER INSURANCE BEEN OBTAINED FOR THE TANK? (If "YES", provide the name of the insurance company, the applicable limit and the cleanup sublimit)
14. IF BUILDING IS UNDER CONSTRUCTION, IS THE APPLICANT THE GENERAL CONTRACTOR? 11. ANY LEAD PAINT?
a. IF "YES", IS THERE A SAFETY NET? (no explanation needed)
ORIGINAL OCCUPANCY:
WAS THE STRUCTURE ORIGINALLY BUILT FOR OTHER THAN A PRIVATE RESIDENCE AND THEN CONVERTED? 10.
IS THERE A TRAMPOLINE ON THE PREMISES? 9.
LAND USED FOR: # OF ACRES:
IS PROPERTY SITUATED ON MORE THAN ONE ACRE? 5.
6. ANY UNCORRECTED FIRE OR BUILDING CODE VIOLATIONS?
IS THE DWELLING / HOME FOR SALE? (no explanation required) 7.
8. IS PROPERTY WITHIN 300 FEET OF A COMMERCIAL OR NON-RESIDENTIAL PROPERTY? (If "YES", describe in detail) BREED ANIMAL TYPE
BITE HISTORY (Y/N) DESCRIPTION:
BITE HISTORY (Y/N) BREED
ANIMAL TYPE
HOME OFFICE/BUSINESS
DAY CARE # OF CHILDREN: TELECOMMUTER
FARMING
DESCRIPTION: # PART TIME:
# FULL TIME:
4. ARE THERE ANY ANIMALS OR EXOTIC PETS KEPT ON PREMISES?
Y / N EXPLAIN ALL "YES" RESPONSES UNLESS STATED OTHERWISE
GENERAL INFORMATION - RESIDENTIAL LOC #: 1. ANY BUSINESS CONDUCTED ON PREMISES?
2. ANY RESIDENCE EMPLOYEES?
3. ANY FLOODING, BRUSH, FOREST FIRE OR LANDSLIDE HAZARD? HAS INSURANCE BEEN TRANSFERRED WITHIN AGENCY? 6.
GENERAL INFORMATION (continued)
8. DURING THE LAST FIVE (5) YEARS [TEN (10) YEARS IN RHODE ISLAND], HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY ? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.)
DOES APPLICANT OWN ANY RECREATIONAL VEHICLES (SNOW MOBILES, DUNE BUGGIES, MINI BIKES, ATVS, etc), NOT SCHEDULED ON THIS POLICY? 7.
YEAR MAKE MODEL BODY TYPE
Y / N EXPLAIN ALL "YES" RESPONSES
SEND BILL
REFERENCE / LOAN #:
ITEM: CLASS:
ITEM DESCRIPTION
INTEREST IN ITEM NUMBER LOCATION: BUILDING: VEHICLE: BOAT: ITEM
EVIDENCE:
RANK: CERTIFICATE INTEREST NAME AND ADDRESS
ADDITIONAL INSURED
LOSS PAYEE MORTGAGEE LIENHOLDER
TRUSTEE
ADDITIONAL INTEREST (Attach ACORD 45, Additional Interest Schedule, if more space is required)
SEND BILL
REFERENCE / LOAN #:
ITEM: CLASS:
ITEM DESCRIPTION
INTEREST IN ITEM NUMBER LOCATION: BUILDING: VEHICLE: BOAT: ITEM
EVIDENCE:
RANK: CERTIFICATE INTEREST NAME AND ADDRESS
ADDITIONAL INSURED LOSS PAYEE MORTGAGEE LIENHOLDER TRUSTEE WATERCRAFT SECTION PERS UMBRELLA APPLICATION SECTION
EARTHQUAKE APPLICATION PERSONAL INLAND MARINE SECTION
MOBILE HOME SUPPLEMENT FLOOD EXCLUSION NOTICE LEAD FREE PAINT CERTIFICATION
REPLACEMENT COST ESTIMATE
PHOTOGRAPH
PROTECTION DEVICE CERTIFICATE
SOLID FUEL SUPPLEMENT STATE SUPPLEMENT(S) (If applicable)
RESIDENCE BASED BUSINESS SUPP WINDSTORM LOSS MITIGATION REMARKS / ATTACHMENTS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US. (Not applicable in AZ or MN)
IMPORTANT: ARIZONA residents should be given ACORD 38 AZ, Privacy Notification; In MASSACHUSETTS, credit scoring information may be used to determine your eligibility for insurance, and not for rating purposes; MINNESOTA residents should submit ACORD 38 MN to authorize release of personal information; Credit scoring cannot be used in OREGON for renewals unless requested by the insured.
APPLICABLE IN ARIZONA: BINDERS ARE EFFECTIVE FOR NO MORE THAN 90 DAYS; APPLICABLE IN COLORADO: THE INSURER HAS THIRTY (30) BUSINESS DAYS, COMMENCING FROM THE EFFECTIVE DATE OF COVERAGE, TO EVALUATE THE ISSUANCE OF THE INSURANCE POLICY; APPLICABLE IN MARYLAND: THE INSURER HAS 45 BUSINESS DAYS, COMMENCING FROM THE EFFECTIVE DATE OF COVERAGE, TO CONFIRM ELIGIBLITY FOR COVERAGE UNDER THE INSURANCE POLICY; APPLICABLE IN MICHIGAN: THE POLICY MAY BE CANCELLED AT ANY TIME AT THE REQUEST OF THE INSURED.
(Applicant's Initials):
THIS BINDER MAY BE CANCELLED BY THE COMPANY BY NOTICE TO THE INSURED IN ACCORDANCE WITH THE POLICY CONDITIONS. THIS BINDER IS CANCELLED WHEN REPLACED BY A POLICY. IF THIS BINDER IS NOT REPLACED BY A POLICY, THE COMPANY IS ENTITLED TO CHARGE A PREMIUM FOR THE BINDER ACCORDING TO THE RULES AND RATES IN USE BY THE COMPANY. THE QUOTED PREMIUM IS SUBJECT TO VERIFICATION AND ADJUSTMENT, WHEN NECESSARY, BY THE COMPANY.
INSURANCE BINDER EFFECTIVE DATE EXPIRATION DATE
TIME
THIS COMPANY BINDS THE KIND(S) OF INSURANCE STIPULATED ON THIS APPLICATION. THIS INSURANCE IS SUBJECT TO THE TERMS, CONDITIONS AND LIMITATIONS OF THE POLICY(IES) IN CURRENT USE BY THE COMPANY.
12:01 AM NOON COVERAGE IS NOT BOUND
IF THE "BINDER" BOX TO THE LEFT IS COMPLETED, THE FOLLOWING CONDITIONS APPLY:
THIS BINDER MAY BE CANCELLED BY THE INSURED BY SURRENDER OF THIS BINDER OR BY WRITTEN NOTICE TO THE COMPANY STATING WHEN CANCELLATION WILL BE EFFECTIVE.
Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not applicable in all states, consult your agent or broker for your state's requirements.)
PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR
NATIONAL PRODUCER NUMBER (Required in Florida)
PRODUCER'S SIGNATURE
DATE APPLICANT'S SIGNATURE
PRODUCER'S NAME (Please Print) STATE PRODUCER LICENSE NO
IN KANSAS, ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.
IN THE DISTRICT OF COLUMBIA, WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS, IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.
IN WASHINGTON, IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.
IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, MAY BE COMMITTING A FRAUDULENT INSURANCE ACT, WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES.
IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, DC, FL, HI, KS, MA, MN, NE, OH, OK, OR, VT or WA; in LA, ME, TN and VA, insurance benefits may also be denied)
APPLICANT'S STATEMENT: I HAVE READ THE ABOVE APPLICATION AND ANY ATTACHMENTS. I DECLARE THAT THE INFORMATION PROVIDED IN THEM IS TRUE, COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. THIS INFORMATION IS BEING OFFERED TO THE COMPANY AS AN INDUCEMENT TO ISSUE THE POLICY FOR WHICH I AM APPLYING.
